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The Painful Truth: Treating Pain in the ED

A child's arm is red, swollen, and misshapen. As tears roll down his face, he describes to the physician his fall from the skateboard he loves.

An elderly woman's face is white as she describes the pain in her abdomen to the nurse at the triage station.

There are many reasons these patients appeared in the emergency department, but to them, pain is their overriding symptom. While the focus on treating pain is intense and unblinking, most emergency physicians who study the topic say the treatment of pain in the emergency department still falls short of the goal of the “painless emergency department.”

“We have seen some improvement in some areas,” said Knox Todd, MD, MPH, the director of the Beth Israel Pain and Emergency Medicine Institute in New York City. “There have been incredible increases in documentation of pain intensity,” he said, which can be attributed to encouragement from the American Pain Society and new requirements from the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).

Previously, he said, pain severity was documented no more than 10 percent of time. Now that is up to 80 to 90 percent of the time in the emergency department, he said.

“If you look at data from the National Center for Health Statistics from 1997 to 2001, the proportion of patients who received analgesia in the emergency department increased 18 percent over that,” he said. That, he said, is a significant increase.

Increased Awareness

“Why is pain treatment in the emergency department an issue?” asked David Fosnocht, MD, an assistant professor of emergency medicine at the University of Utah School of Medicine. “There's been a great deal of interest lately. It started with a landmark article in 1989 by Wilson that documented the lack of pain treatment in the emergency department.”

In that article (Am J Emerg Med 1989;7[6]:620), emergency medicine researchers at Akron City Hospital found in a chart review that 56 percent of 198 patients admitted through the emergency department with acutely painful medical and surgical conditions received no pain-relieving medication while in the emergency department. Of those who did receive pain medication, 69 percent waited more than an hour before getting the medicine and 42 percent waited more than two hours.

In 2001, Indiana University School of Medicine researchers led by William Cordell, MD, found that 1,019 of 1,665 patients reported pain as a complaint when they arrived at the emergency department. (Acad Emerg Med 2001;8[5]:428.) That, the researchers said, indicated the importance of pain as a reason for visiting the ED.

The past three or so years have seen an increased awareness of pain treatment in the emergency department, said Dr. Fosnocht, with more research being done, in part because of hospital and national requirements. “A big part of the reason for the lack of treatment is the lack of focus on it,” said Dr. Fosnocht. “When people come to the emergency department, we are trained as emergency physicians to find out what's wrong. We anticipate the worst, and take care of the life-threatening problem that's going on. The treatment of pain often gets left behind as we try to treat what may or may not be a life-threatening event. Often, the first time we think about giving something for pain is at the time of discharge,” he said.

At the University of Utah, he sees patients who come to the emergency department because of recreational accidents and injuries that are very painful. They are a good population in which to study treatment of pain, he said.

Although acute pain has gotten much of the attention, he said all chronic pain starts somewhere. “There is an increasing awareness that our treatment of acute pain initially may have a large impact on patients who go on to develop chronic pain,” said Dr. Fosnocht. “If we can avoid initial poor treatment of the painful event, we may be able to ward off chronic pain later.” That emphasizes the importance of treating pain in the emergency department, he said.

“The doctors scrutinized [for narcotic prescribing] are those who have engaged in suspect practices in an office-based practice, not in the emergent visits we see.” - Dr. Knox Todd

In addition, he said, the emergency department is, among many other things, a safety net for patients who cannot receive treatment for their pain elsewhere and for those who have no access to a pain clinic. “This is something we haven't addressed well as a society,” he said. “When people have chronic pain, the typical response is not a positive one from the staff or physicians. Patients get frustrated with that as well.”

Dr. Fosnocht said he has concentrated on refining methods of measuring acute pain. “One thing everyone struggles with is defining pain,” he said. “The individual variations among patients are quite dramatic. One of the difficulties we face as clinicians is deciding what is an appropriate level of intervention for the same injury to different patients. Patients respond to pain in different ways. You can have the same wrist fracture, and one patient will say the pain is ‘2' while another may say it's a ‘10.' ”

“Despite the fact that it's the same injury, do we treat the pain in the same way?” he asked. “One of our focuses right now is assessing what different pain scales mean and to develop better pain scales that reflect the level of pain patients are feeling.”

“The treatment of pain often gets left behind as we try to treat what may or may not be a life-threatening event.” - Dr. David Fosnocht

For example, he said, if a patient says his pain is a “6,” does that mean the patient can't function? If the pain is a “2,” does that mean the person has some limited use of the injured limb? “Do patients with high pain scale scores and injuries we may not see as severe go on to develop chronic pain because they are sensitized in some way?” he asked.

Opiate Phobia

One obstacle may be a fear that physicians and patients alike share: opiate phobia. Dr. Fosnocht said physicians tend to shy away from providing narcotic analgesia, but he noted that drug-seeking patients are in the minority of those who need narcotics. “Our mistake is that we don't adequately treat most patients out of fear of providing narcotics to someone who is drug-seeking or using the medication inappropriately,” he said.

Dr. Todd said the fear that authorities such as the U.S. Drug Enforcement Agency or state medical licensing boards will pursue doctors for inappropriate prescribing is unfounded. “They do not go after emergency physicians,” he said. “The amount of drug prescribed in the emergency department is minuscule, and it is for a short period of time. The doctors who are scrutinized are those who have engaged in suspect practices in an office-based practice, not in the emergent visits we see.”

Ensuring that patients receive adequate pain treatment during procedures is an important part of treatment in the emergency department, said Steven Andrew Godwin, MD, an assistant professor of emergency medicine at the University of Florida College of Medicine, who helped develop guidelines for conscious sedation during emergency department procedures. (Ann Emerg Med 2005;45[2]:177.)

“It is seen currently as a pressing issue as emergency physicians across the country in academic and community centers were using a wider variety of agents as their choice for sedation and analgesia for different procedures,” said Dr. Godwin. Many of those included propofol, etomidate, and ketamine — agents historically used by and restricted to anesthesia in some areas.

In his work with a group from the American College of Emergency Physicians to set clinical guidelines for conscious sedation, Dr. Godwin and his colleagues evaluated the literature in the field. “We found that almost all conscious sedation or moderate sedation and procedural studies were being performed by emergency physicians in the area of propofol, etomidate, and ketamine. The vast majority of the studies in these areas were being performed by emergency physicians.” He said although the studies were small, they demonstrated that the drugs could be used safely by emergency physicians.

Saying it was appropriate for emergency physicians and ACEP to develop guidelines for the use of these agents in procedures, Dr. Godwin noted that formal evidence-based guidelines gives emergency physicians the information they need to make choices, to go to hospital credentialing committees, and to acquire support for the use of these agents in their patients. “This is important because it is a patient care issue. We want to provide the best care possible. We deal in a traumatic environment in which patients have painful procedures. It is important to have safe, efficacious, and often fast-acting agents to allow our patients to go home without long durations of stay in the emergency department. It is the best patient care.”

Guidelines Needed

Dr. Todd agreed, saying that procedural sedation is an issue emergency medicine must confront. “Where does the emergency physician's responsibility end and the anesthesiologist's begin? I think we have gone from a shrill discussion to a reasoned one where the emergency physicians have explicit guidelines and procedures to follow to conduct procedural sedation in a safe manner.”

Much work remains to be done, said Dr. Todd, a pioneer in pain treatment in the emergency department. “There are a number of conditions that continue to be poorly treated,” he said. “In particular, we do a poor job of treating sickle cell crisis. We treat almost none of these, and we do no research in that area. There are no guidelines specially set up as policies about how we should treat those patients.”

Dr. Todd is working with sickle cell researchers in California and Colorado to develop National Institutes of Health consensus conferences around sickle cell disease, and he said the first should be guidelines for pain treatment. Emergency physicians also need to look at substance abuse issues. Emergency physicians are often suspicious of patients with pain complaints, he said, and although identifying patients with substance abuse is difficult, “we have nothing to back them up in this area,” he said. “Often we deny patients adequate pain treatment because of suspicions of drug abuse. I don't think we have a leg to stand on without research.”

While Dr. Fosnocht said he hopes to see a generational change in attitudes toward pain treatment as younger doctors come into emergency medicine, Dr. Todd is less sanguine. “Education goes both ways,” said Dr. Todd. “The educational system has traditionally trained physicians not to treat pain by example. It is not in the curriculum. It is not in the residency training. The model curriculum for clinical practice does not include pain management other than as an adjunct to other procedures. There are a lot of motivated educators who try, but in the face of a medical culture that doesn't value that part of education, it's hard to know what kind of impact it has. I'd prefer to see something happen faster.”

He is particularly interested in technology that will help speed painless experiences. Needleless approaches to pain care or transnasal or transdermal routes of medication delivery are apt examples. “The idea of running a painless emergency department and then sticking a needle in someone seems at loggerheads,” Dr. Todd said. He also sees promise in new regulations that require continuing medical education on pain treatment in some states. “We will see more mandated pain education efforts in a variety of states,” he predicted.

“This is important because it is a patient care issue.” - Dr. Andy Godwin

Education cannot be limited to physicians, but has to focus on helping patients accurately assess their pain. “In the emergency department setting, as many as 30 to 40 percent of folks rate their pain as a 10 on a 1 to 10 scale,” said Dr. Fosnocht. “That is different from a post-operative setting, where you would expect patients to have severe pain. They rate their pain in a more bell-shaped curve, and most don't have a pain rating that high. I don't know why that is. Some may think that in order to get anything, you have to scream and yell for attention. Then, it is often not an expected event to come to the emergency department. You go into surgery expecting pain. It could be related to anxiety and fear of the unknown. We are placing a lot of emphasis on the pain scale to answer a lot of things.”

What does it mean when up to 40% of patients rate their pain as a 10 of 10?

His work focuses on developing a better scale that is more specific than a general 1 to 10 rating. The current numerical scale is one of several available, but is widely used because it is easy. “But for many reasons, we don't know what the numbers mean. As clinicians, we don't know what do to when 30 to 40 percent of patients say their pain is 10 of 10.

“A large part of the answer is education, and that includes patients as well. Some of the anxiety may be alleviated with a verbal intervention. We say, ‘We care about your pain. We will help take care of your pain.'”

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